A Literature Review of Youth that Self Injure by Renee Baker, August 2010
What Do We Know About Self Mutilation?
Historically, self-mutilation was considered a form of suicidal behavior until suggested otherwise by Karl Menninger in his 1938 book, Man Against Himself, in which he postulated that self-mutilation was a type of partial suicide or a local-self destruction used to avert a complete or total suicide (as cited in Bolognini, Plancherel, Laget, Stephan and Halfon, 2003). Hence, self-mutilation is defined such that it is self-injurious behavior with no intention of suicide. To distinguish self-mutilation from say smoking that unintentionally causes lung cancer, there is a deliberate attempt to destroy one’s own body tissue or organs (Nock, 2009). Additionally, self-mutilation is pathologically distinct from culturally sanctioned bodily self-modification rituals such as ear piercing, body sculpting, branding and genital circumcision (Bolognini, et al., 2003). These sanctioned types of bodily modification are not meant to inflict a violent and disfiguring injury, but are done for ornamentation, social or spiritual purposes (Hicks, 2008). Self-mutilation is also distinct from self-poisoning in which there is no intent on tissue damage (Shiner, 2008).
Self-mutilation has been categorized by Favazza (as cited in Hicks, 2008) into three distinct categories including superficial, stereotypic and major. Superficial self-mutilation is a common form of self-mutilation seen among adolescents and includes such behaviors as cutting oneself with a knife or razor, skin picking, severe nail biting (Brain, Haines, Williams, 2002), stabbing, scratching the skin, burning or scalding the skin, hair pulling and interfering with wound healing (Hicks and Hinck, 2008). Some of the items of choice used to self-mutilate include pencil tips, paper clips, pins, shards of glass, razors, box cutters, scissors and drink can tabs (Hicks and Hinck, 2008). Areas most often cut are wrists, arms, ankles, calves, inner thighs, belly, brassiere line, armpits and feet (Hicks and Hinck, 2008).
Stereotypic self-mutilation is seen generally in autistics and individuals with mental retardation or Tourette’s syndrome and includes such rhythmic behaviors as hitting oneself, head banging, orifice digging, throat and eye gouging, self-biting and joint dislocation (Hicks and Hinck, 2008).
Major forms of self-mutilation are of an extreme nature resulting in significant tissue damage (Lambert and de Man) often completed by those who are either psychotic or intoxicated and include such self-destruction as eye enucleation, genital mutilation or castration, limb amputations and bone breaking (Hicks and Hinck, 2008). Only superficial self-mutilation is considered in the remainder of this report.
Self-mutilation is a complex phenomenon that we are still largely in the dark on and much research is left to be done to understand the factors and etiology (Levenkron, 2006). First, little data exists regarding detailed characteristics and the associating factors of self-injury reaching a clinical severity. Second, there is little data available to make a distinction between suicidal and non-suicidal subsamples of self-injuring patients, which namely show which predictors contribute to develop self-injuring behavior with a previous suicidal history (Csorba, Dinya, Plener, Nagy and Pali, 2009).
The best predictor of self-injuring individuals includes childhood sexual abuse and family violence, and other life experiences such as loss of a parent or guardian, a childhood illness, a history of substance abuse, another family member that self-injures, poor mood regulation and/or a history of eating disorders such as anorexia and bulimia (Moyer, 2008).
Individuals that self-mutilate do so for a plethora of reasons, many of which are not understood. The intentional destruction of tissue has a purpose, but it is not for masochistic pleasure purposes; in other words, the pleasure of pain is not sought by self-mutilators in contrast to those that identify as masochistic (Hicks and Hinck, 2008).
Some report that self-mutilation acts as a catalyst for tension reduction and as such, a tension reduction model has been constructed to represent a simple drive reduction mechanism (Brain, Haines and Williams, 2002). In such a model, researchers have proposed that when the individual reaches a certain level of intolerable anxiety and tension, individuals injure themselves in order to reduce the unpleasant and escalating feelings (Brain, et al, 2002). According to Haines, any relief, which is temporary, serves to reinforce the behavior and individuals become trapped in a psychophysiological arousal related reinforcement process (as cited in Brain, et al., 2002).
Psychodynamic theorists suggests that self-mutilation is performed as a way to gain control over urges for sex or death (Nock, 2009). In 1960, Zuk offered support that aggressive impulses in self-injury are sometimes directed against an external frustrating agent. Zuk suggested that the self-injurer may regress to having an ego of an infantile level with a consequent breakdown of the identification of the ego and the body, where the body is no longer perceived as an extension of the self, but as an object in the environment. When the aggression, for whatever reason, cannot be directed toward the true object, it is extended against the most immediate or nearest object, being the self-injurer’s body. However, Zuk cautions that self-mutilation and self-injury (e.g., self-hitting) may not be equated exactly as self-mutilation may be more of a self-punishing behavior and self-injury more of an other-punishing behavior (Zuk, 1960)
The strong relationships that have been shown between self-mutilation and various psychiatric disorders have led many to conceptualize self-mutilation or non-suicidal self-injury in general as a psychiatric disorder (Nock, 2009). However, self-mutilation is not a symptom of any one psychiatric disorder leading some to believe that self-mutilation should be its own psychiatric disorder (Nock, 2009). Currently, the American Psychiatric Association indicates that cutting behavior and self-injury is associated with a variety of factors including borderline personality disorder, trauma, abuse, eating disorder, low self-esteem, and perfectionism (American Psychiatric Association [DSM-IV-TR], 2000).
Tatman offers a feminist theological perspective in that self-mutilation may be interpreted as an act of atonement, or, as the site of an individual’s awful struggle to live, to refuse the annihilation of human life.
Research on etiology is still needed as there appears to be many causes of self-mutilation. An exhaustive list of antecedents has been documented by Hicks and Hinck (2008) and these include situational circumstances that cause unbearable emotional distress as well as impaired or reduced coping skills to manage the situation or the perceived stressors. They summarize the large body of self-mutilation literature and list the reasons of self-mutilation including: to run away from feelings, to feel pain outside rather than on the inside, to cope with emotional feelings, to express anger toward oneself, to overcome numbness and feel alive, to shut off emotions, to gain control of self or others, to call for help by expressing in a nonverbal and serious way, and to manipulate situations or others. (Hicks and Hinck, 2008)
In contrast to what is often thought, self-mutilating behavior is not about causing pain, but about alleviating it (Cross, 2007). It is said to be a private act where the self-mutilator experiences the pain alone. Cutters in particular often report a sense of relief when they see a flow of blood and further describe this as giving them a sense of control (Cross, 2007).
Cross divides self-mutilators into those that feel hyper-stressed and those that feel dissociated (2007). The hyper-stressed feel overwhelmed and unable to cope, they feel exposed and they feel sensitive. When they self-injure, they feel relieved, in control and calm again. The dissociated feel numb, lost, alone, disconnected and unreal. When they self-injure, they feel real, alive, functioning and able to act again (Cross, 2007).
Self Mutilation Studies Among Adolescents
Self-injurious behavior usually appears in the early to middle adolescent years and are seen across ethnicities and gender lines (Moyer, 2008). Rates of self-mutilation among the general U.S. adult population and clinical adult population have been estimated respectively at 4% and at 21% (Briere and Gil, 1998). By contrast, rates of self-mutilation among U.S. adolescent community samples and adolescent psychiatric inpatient samples were found to be respectively 14-39% and 40-61% (as summarized by Nock and Prinstein, 2005). Vanderhoff and Lynn (as cited in Cross, 2007) report that self-injury among American college students was measured at a 32% rate.
Even with alarming rates, studies among adolescents (especially LGBT adolescents) that self-mutilate have not received a great deal of attention in the literature and remain a poorly understood behavioral phenomenon (Nock and Prinstein, 2005). Even aside from youth that self-mutilate, gay youth alone as a group were not studied at all until 1972 and it took another 15 years passing before the next study appeared in the literature (Remafedi, 1987). Studies of transgender youth that self-mutilate are absent all-together from the literature based upon an EBSCO database search.
One study in Switzerland examined the relationship between suicide attempts and self-mutilation by adolescents and young adults (Bolognini et al., 2003). They found that while there was a correlation between those that attempted suicide and those that self-mutilated, that there was only a partial overlap attesting that suicide and self-harm might correspond to two different types of behavior. They additionally found that there was an association with eating disorders, notably bulimia, with those that harm themselves. An association with anorexia nervosa was also observed. They concluded that both anorexia and self-mutilation can be interpreted as being linked to body dissatisfaction, asceticism, or a pervading sense of ineffectiveness, which often implies self-punishment (Bolognini et al., 2003).
In another study in Hungary, 105 adolescent outpatients suffering from self-injurious behavior (28 males and 77 females ranging from 14 to 18 years of age) were followed over an 18 month period. Over this period, the motivation of patients to stop self-mutilating was low. Two-thirds of the individuals practiced impulsive type self-mutilation and about 30% practiced a more premeditated self-mutilation. Scratching and cutting were the most prevalent type of self-mutilation behavior employed. Researchers measured the time passed between the initial thought about self-mutilating and the actual self-mutilation act. They found that 19% of youth spent hours and days thinking about it ahead of time, 27% thought about it for 6 minutes to an hour, and 55% spent less than five minutes between the thought and the action. They found there were no significant sex and age factors. (Csorba, Dinya, Plener, Nagy and Pali, 2009).
In Germany, 2863 families with children aged 7-17 participated in the BELLA study and found that what parents report about their children differ than what the children report. It was found that 2.9% of the adolescents 11-17 years of age reported self-mutilation or suicidal attempts within the previous six months. But, for parents, the prevalence rates reported over the same six months was only 1.4%. The study also found that reports of self-mutilation or suicidal attempt for children 11 years of age and under was very rare, but the occurrence of suicidal thoughts was similar to the rate for adolescents. No associative factors related to gender were found in this study.
The most pertinent study found in regard to our research topic of interest was that of self-mutilation and homeless youth by Tyler, Whitbeck, Hoyt and Johnson from the University of Nebraska-Lincoln (2003). The results of their study follow-suit to the study desired herein, in particular, to that of self-mutilation and LGBT homeless youth in the Dallas area and associated with Youth First Texas.
The UNL team recognized that self-mutilation has been overlooked in studies of homeless and runaway youth, and given that they have high rates of abuse and mental disorders associated with self-mutilation, they provide a highly relevant non-clinical sample to investigate factors associated with self-mutilation (Tyler et al., 2003). The UNL study was based on interviews with 428 homeless youth aged 16 to 19 from four different Midwestern states. Prior to the UNL study, no study on self-mutilation and homeless youth had been researched or reported.
The UNL team had several motivations for doing the research on this adolescent group including the fact that this group likely had a high rate of child abuse trauma, which is usually associated with self-mutilation in the literature, that this group had many stressors in the streets or previously from home, and that this group has a lack of current adult support.
A central issue of the research was to explain why some adolescents self-mutilate while others do not. The study improves upon previous studies by using a large sample multivariate analysis to examine factors associated with self-mutilation among the nonclinical homeless and runaway youth. The sample of 428 homeless youth included 187 males and 241 females aged 16 to 19 years old living in shelters, on the street, or independently with friends or transitional living, because they were either pushed out or ran away.
Among the sample of homeless youth, 69% indicated they had participated in self-mutilating behavior and 12% reported needing medical attention as a result. No difference between males and females was found. The most prevalent form of mutilation was cutting or carving the skin. Youth who experienced severe trauma as a child were more likely to self-mutilate. The end result was that sexual abuse before running away, ever having stayed on the street, deviant subsistence strategies, and major depression were associated with an increase in the number of self-mutilating acts.
References
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